[Solved]: Patient Name: Mallory Decker DOB: 01-01-68 Sex: F Date…

Patient Name: Mallory Decker DOB: 01-01-68 Sex: F Date of Service: 06-17-XX Attending Physician: Carl Jenson, MD Reason for Visit: Cardiac arrest History of Present Illness: Mrs. Decker presents to the ED via EMS in cardiac arrest. The patient’s husband states he woke up this morning, and heard the pt making noises, he thought she was asleep and having a bad dream, husband then states noises went on for a while so he went to check on her and he saw the blood coming out from her mouth. The pt’s husband immediately called EMS. Per EMS, pt was in resuscitated cardiac arrest with a BP of 125/97, CPR started immediately on scene. Per EMS, they were initially called for SOB, pt was alive when husband call EMS. Per EMS, when they arrived on scene, pt was in adenyl respiration then went into asystole, her glucose level was sugar 52 and was given amp of 50, EMS noticed the blood on her mouth and lips at the scene. Per EMS, the pt’s husband panicked on scene, pulse was not found on scene, IO was placed on pt’s right tibia. Pt was SOB last night and refused to come to the ER. Per EMS, prior to arriving to ED, the pt had 1800 liters of fluid. CPR taken over by ER staff on arrival. Medical History: Noncontributory Surgical History: L BKA Medications: Oxycodone Allergy: Levaquin, Lasix, Protonix, Effexor, Pulmicort. Perforomist, Solu-Medrol, and Klonopin. Review of Systems: CONSTITUTIONAL: No fevers, chills, sweats EYES: No recent visual problems ENMT: + Blood on mouth and lips. RESPIRATORY: No shortness of breath, cough CARDIOVASCULAR: + Cardiac arrest. GASTROINTESTINAL: No nausea, vomiting, diarrhea GENITOURINARY: No hematuria HEMA/LYMPH: Negative for bruising tendency, swollen lymph glands ENDOCRINE: Negative for excessive thirst, excessive hunger MUSCULOSKELETAL: No back pain, neck pain, joint pain, muscle pain, decreased range of motion. INTEGUMENTARY: No rash, pruritus, abrasions NEUROLOGIC: No seizures. PSYCHIATRIC: No anxiety, depression Vitals: Temperature: 99.8deg F Pulse: 80 Blood Pressure: 120/80 SpO2: 100% Physical Examination: GENERAL: Unresponsive with a king air way in place. HEAD: No signs of head trauma. Head shows no deformity or injuries. EYES: Pupils are equal, round, reactive to light and accommodation bilaterally, no nystagmus, no scleral icterus or injection, visual fields intact bilaterally. Extra ocular movement are not detected. EARS: Hearing grossly intact. External canals are clear bilaterally. MOUTH: Tongue is midline, King airway in place. Oral mucosa pink and moist, gross blood in pharynx, appears to be GI bleeding source. Dry blood at nares of nose bilaterally, gross blood around mouth. NECK: No carotid bruits. Supple, nontender, no masses or lymphadenopathy, no JVD, trachea midline without deviation. CHEST: Respiratory only by bag mass ventilation, breath sounds diminished light crackles throughout. CARDIAC: Regular S1 S2. HR is regular 80s. VASCULAR: No pedal edema. Peripheral pulses normal and equal in all extremities. ABDOMEN: Soft, without detectable tenderness. No pain with palpation anteriorly. No CVA tenderness. No sign of distention. No rebound or guarding, and no masses palpated. Bowel Sounds normal. MUSCULOSKELETAL: No voluntary movement, no obvious injury. Maintained muscle tone and DTR. Left BKA amputation from MVA in 2001, IO line in her right tibia. NEUROLOGIC EXAM: Alert and oriented x 3. No focal sensory or strength deficits. Speech normal. Follows commands. PSYCHIATRIC: Mood normal. SKIN: no focal lesions, dusky, perioral cyanosis Laboratory Tests: WBC: 21.6 (Ref Range 4.2-10.7) RBC: 3.10 (Ref Range 4.0-5.20) Hemoglobin: 7.7 (Ref Range 11.5-15.4) Hematocrit: 28.5% (Ref Range 34.0-45.8) MCV: 91.9fl (Ref Range 82.7-97.3) MCH: 24.7pg (Ref Range 27.0-33.0) Platelets: 211 (Ref Range 155-400) MPV: 9.8fl (Ref Range 7.5-11.2) Neutrophils: 75% (Ref Range 50-75) Lymphocytes: 11% (Ref Range 20-44) Monocytes: 5% (Ref Range 0-9) Sodium: 137mmol/L (Ref Range 137-145) Potassium: 5.4mmol/L (Ref Range 3.6-5.1) Chloride: 104mmol/L (Ref Range 99-109) Carbon Dioxide: <5mmol/L (Ref Range 22-29) Anion Gap: 31 (Ref Range 7-16) BUN: 64mg/dl (Ref Range 7.0-19.0) Creatinine: 6.76mg/dl (Ref Range 0.57-1.11) eGFR: 6 (Ref Range >=60) Glucose: 184mg/dl (Ref Range 65-99) Lactic Acid: 22.0mmol/L (Ref Range 0.5-2.2) Calcium Level: 6.8mg/dl (Ref Range 8.4-10.2) Phosphorus Level: 14.0mg/dl (Ref Range 2.3-4.7) Magnesium Level: 2.4mg/dl (Ref Range 1.6-2.6) Total Bilirubin: 0.9mg/dl (Ref Range 0.2-1.2) Aspartate Amino Transf (AST/SGOT): 4331 U/l (Ref Range 5-34) Alanine Aminotransferase (AL T/SGPT): 2028 U/l (Ref Range 6-55) Alkaline Phosphatase: 141 U/l (Ref Range 38-126) Ammonia: 428umol/L (Ref Range <51) Troponin I: 5.494ng/nl (Ref Range 0.00-0.028) B-Type Natriuretic Peptide Total Protein: >500pg/ml Albumin: 2.3gm/dl (Ref Range 3.5-5.0) Albumin/Globulin Ratio: 1.2 (Ref Range 1.1-2.2) Blood Gas Puncture Si